An SSCM/ASHP Joint Guideline, this is an update to the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient."
This document is an update of the previous two guidelines for the use of neuromuscular-blocking agents (NMBAs) in the critically ill adult patient, published in 1995 and 2002. The previous guidelines focused on 1) indications for the use of NMBA, 2) recommendations on specific drugs, and 3) attenuation, if not prevention, of the major complications and adverse effects associated with the use of NMBAs in the critically ill adult patient. This document incorporates new data on the basic science and clinical use of NMBAs in the ICU. NMBAs have new uses, such as for attenuation of shivering associated with therapeutic hypothermia in survivors of cardiopulmonary resuscitation and in the treatment of patients with early acute respiratory distress syndrome (ARDS). However, the use of NMBAs has decreased, due to clinician concerns about adverse effects of NMBAs, including ICU-acquired weakness and prolonged duration of mechanical ventilation, thrombosis and thromboembolism, and patient awareness during paralysis. After decades of experience with these medications, we recognize that various patient populations have differing responses to NMBAs or require the use of specific monitoring protocols when receiving NMBAs.
The current guidelines have expanded upon the previous two guidelines to include information on the indications and recommendations for use of NMBAs, as well as more information on the nursing management of the critically ill adult receiving NMBAs, on mechanical ventilation management for patients receiving NMBAs, on techniques and therapies to decrease complications and adverse effects related to the use of NMBAs, and on specific patient populations that may benefit from NMBAs.
Most importantly perhaps, in contrast with previous versions of these guidelines, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to summarize data, assess quality of evidence, and determine the strength of the recommendation when appropriate.
The recommendations are not absolute requirements, and therapy should be tailored to individual patients taking into account patients’ values or preferences, site or specific clinician expertise, and equipment availability in a particular ICU. The use of NMBAs requires an appropriate protocol that includes, but is not limited to, management of mechanical ventilation, analgesia, sedation, nursing care, and point-of-care equipment to monitor the degree of neuromuscular blockade. It is possible that individual recommendations based on evidence from a specific patient population may not be generalizable to a larger critical care population. We have factored these considerations into our recommendations and have described important subgroup considerations when deemed appropriate. The release of data from ongoing studies and from future research trials may stimulate the Guidelines Update Committee of the American College of Critical Care Medicine to revise these clinical practice guidelines, but, until such time, guideline application by clinicians should always be modified based on new evidence, as it becomes available.